Clinical Documentation Improvement Manager

Overview

The Clinical Documentation Improvement (CDI) Manager also has experience as a Second Level Reviewer, certified in CDI with a broad clinical knowledge base and understanding of DRG documentation requirements. The role reports directly to the Director of CDI and manages daily CDI operations and activities.

Responsibilities and Duties

• Oversee daily Clinical Documentation Integrity (CDI) operations and staff activities.
• Lead, coach, mentor, and evaluate CDI specialists to ensure high performance and professional development.
• Monitor documentation quality, query practices, productivity, and departmental performance metrics.
• Collaborate with physicians, advanced practice providers, coding, case management, quality, and revenue cycle teams to improve clinical documentation accuracy and completeness.
• Develop and deliver provider education related to documentation requirements, coding regulations, severity of illness (SOI), risk of mortality (ROM), and quality measures.
• Ensure compliance with CMS regulations, coding guidelines, accreditation standards, and industry best practices.
• Analyze CDI data and trends—including Case Mix Index (CMI), query response rates, CC/MCC capture, and denial metrics—and implement improvement strategies.
• Support accurate reimbursement through complete and compliant clinical documentation.
• Assist with audits, denials management, and regulatory reviews related to documentation and coding.
• Partner with Quality and Patient Safety teams to improve outcomes, risk adjustment, mortality measures, patient safety indicators (PSIs), and publicly reported quality metrics.
• Establish departmental goals, monitor key performance indicators, and provide regular reports to executive leadership.
• Complete concurrent secondary reviews of targeted patient populations to identify missed opportunities and accurate selection of principal diagnosis.
• Act as liaison between the Coding Department and the Clinical Documentation Specialist to reconcile discrepancies in DRG assignment.
• Analyze and interpret clinical data to identify gaps, inconsistencies, and opportunities for improvement; query providers using concurrent or retrospective processes and follow up to ensure queries are answered.
• Assign the appropriate DRG, MCCs, and CCs to each record reviewed.
• Organize and perform work responsibilities effectively and efficiently.
• Maintain strict patient confidentiality, adhering to HIPAA guidelines.
• Demonstrate standards of performance (ownership, teamwork, communication, compassion) that support patient satisfaction and principles of service excellence.
• Perform other duties as assigned.

Qualifications

• Registered Nurse/BSAN, RHIA, RHIT, or related clinical allied health degree required; Physician Assistant (PA) preferred.
• Licensure/Certifications: CCS, CCDS, or CDIP required.
• Minimum of 5 years’ experience as a Clinical Documentation Specialist (7+ years preferred).
• Minimum of 2 years supervisory experience (3‑5 years preferred).
• Advanced clinical expertise and extensive knowledge of complex disease processes with broad inpatient experience.

Physical Demands and Work Environment

• Varied physical activities, including moving about within and outside of all hospital properties for long periods.
• Ability to respond quickly and effectively to emergency and non‑emergent situations.
• May be required to assist in controlling disorderly conduct or combative patients.
• Must be able to exchange accurate information with patients, families, peers, and medical personnel.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Workplace Culture

“Experience Memorial” is more than a slogan; it reflects the care provided to patients and the commitment to the community and team members. As a nationally certified Great Place to Work, Lake Charles Memorial Health System offers an organizational culture that supports exceptional patient care, employee well‑being, professional growth, and celebrates individual contributions.